GW1-2022-08379_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL �Ia.�WATER:zorlEs ..
Well Contractor Name FROM TO DESCRIPTION
ft. ft, i
A - 4459 ft. ft.
NC Well Contractor Certification Number ppp�aa� ='15.OUTER CASING'for"mulh,caseil=wells 012 LWER if a licable -
GEOLOGIC EXPLORATION ' t FROM To DIAMETER' THICKNESS MATERIAL
�" ft. ft. in
Company Name o �Ort
��� [ •`16�INNER CASING 6R TCIBING eothermal closed<loo ;r -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits#.e.UIC,County,Slate ariar� s (JnSI 0.0 ft. 10.0 ft 2.0 1° SCH 40 PVC
:: •�
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN ".:i
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft' 20.0 It" 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) .,,18.GROUT ;:°<�l
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 5.0 It' PORTLAND BENTONRE SLURRY
[EMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
°.19.SAND/GRAVEL PACK if applicable)
>":
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 8.0 ft' 20.0 it- 20-40 FINE SILICA SAND
❑Experimental Technology []Subsidence Control ft. ft.
❑Geothermal(ClosedLoop) ❑Tracer 20:DRILLING'LOG attach adilftional sheets if necessa"
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/ruck type rain size,etc.
0.0 ft- 4.0 ft- SILTY CLAY
4.Date Well(s)Completed: 04/13/22 Well ID# MW-20 4.0 ft- 20.0 ft- SANDY SILT
5a.Well Location: ft' ft
SAAB ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
608 EAST MCNEILL STREET LILLINGTON 27546 ft. ft.
ft.
Physical Address,City,and Zip ft. ,
HARN ETT 21•REMARKS,N
County Parcel Identification No.(PIN) BENTONITE SEAL-5.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 23' 25.32" N 780 48' 32.62" W
04/25/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the mvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the ivell owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20.0 (ft.)
For multiple wells list all depths iii dierent(example-3@200'and 2@I00D Submit this GW-1 within 30 days of well completion per the following:
10.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifivater level is above casing,use"+"
11.Borehole diameter: 8.0 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh;NC 27699-1 61 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018